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234342 > Total PArenteral Nutrition > Flashcards

Total PArenteral Nutrition Flashcards

1
Q

starting with info from review slides

What is included in the daily routine monitoring of a client on TPN?

A
  • TPN Flow rate checked hourly
  • careful I&O’s, assessing lungs and extremities (fluid retention), weight,
  • glucose levels q6h or as ordered and lab work parameters,
  • IV/CVAD site,
  • infection: fever (VS), increased WBC’s and malaise -(triglycerides if getting fat emulsions)
  • lytes, HCo3 etc in labs and assess for muscle cramps etc if imbalanced
  • proteins: albumin, transferrin, prealbumin

maybe not daily but assess renal and hepatic fx too

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2
Q

can you infuse TPN by gravity?

A

no. use a pump always

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3
Q

your intervention when Your client is showing signs of weight gain, peripheral edema, crackles in lungs and I&O imbalance.

A

3 – rate likely needs to be slowed, solution may require titration (by doctor’s order)

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4
Q

How often should the tubing be changed with a peripheral IV receiving TPN with lipids?

A

q24h

with kids it is 12h. fr kids the lipids are gen infused separately. my instructor says that the lipids when given separately gen infuse in 12h anyway

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5
Q

Name 3 medications that are compatible with TPN solutions.

A

Insulin,
Vitamin B12 and
Ranitidine

– Ranitidine and Vitamin B12 is added for some pts but if the pt requires insulin it’s usually administered either SC for IV

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6
Q

What should you watch for should TPN be discontinued abruptly?

A

Patient may become hypoglycemic.

They have a lg amount of sugars in the TPN and then when suddenly withdrawn they will have excess insulin in their blood that will lower their BG too much because they no longer have the glucose fom TPN

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7
Q

what do you do if pt must be disconnected from TPN for a diagnostic etc

A

D10w is what you hang when the pt is going to go to xray or something nad cant have the TPN follow them. You need to conitnue the sugars

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8
Q

What are the main indications for why a client maybe receiving TPN?

A

Non-functioning GI tract (some types of major bowel surgery, paralytic ileus, bowel obstruction, small bowel obstruction, short bowel syndrome, trauma, severe malabsorption, intolerance to enteral feeds, chemo, radiation, bone marrow transplant)
- Extended bowel rest (enterocutaneous fistula, IBD exacerbation, severe diarrhea, moderate to severe pancreatitis)
Pre-operative TPN (pre-op bowel rest, severe malnutrition due to comorbities with non-functional GI tract, severely catabolic (protein breakdown leading to acidosis) patients when GI tract non-usable for more than 4-5 days.
Hypergravida emesis

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9
Q

what are long term indications for parental nutrition

A
  • short bowel sydrome
  • dysmotility syndrome
  • radiation enteritis
  • permanent bowel obstr from tumor
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10
Q

Most common complications related to TPN are:

what is most common?

A 
infection most common
-sludge accumulating in gallbladdercholecystitis
-Liver disease—long term
-Metabolic bone disease—long term
-Allergy
-Catheter related sepsis or bacteremia 
-Hyper/hypo glycemia 
an uncommon complication is refeeeding syndrome (if the pt is vry malnourishes
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11
Q

what is refeeding syndrome

A

my understanding is that when the malnourished pt receives too much PN too quick their BG raises and lots of insulin is released which stimulates glycogen, fat, and protein synthesis. Insulin causes K to enter cells. Cellular processes requires lots of phosphate, potassium, and magnesium and leads to depletion of the lytes as they shift intracellularly. Hypophosphatemia is the hallmark

i dont think we need to now this detail but i never quite got it before!

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12
Q

how is dextrose for peripheral veins

A

it is hard on them d/t high osmolarity

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13
Q

why should a renal or cardiac pt preferrably have TPN by central line

A

CVCs: it is a smaller volume with more concentrated calories

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14
Q

TPN can be administered through a peripheral IV as long as the solution is appropriate.
what is the consideration

A

Solutions containing less than 10% dextrose and are less calorically dense

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15
Q

. Blood glucose levels are very important to maintain in clients on TPN. Why?

A

High glucose levels are associated with cardiovascular events, general infection, systemic sepsis, acute renal failure and death

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16
Q

cards from notes now:

• Well nourished adults can be maint on periph IV (not TPN) up to _____ without difficulty

A

2 weeks

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17
Q

what is TPN and its advantage over eating

A
  1. The administration of totally digested vitamins, minerals, amino acids, dextrose, fat etc. directly into the circulatory system. The advantage is that it gets essential nutrients into a person who is unable to absorb through the GI tract.
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18
Q

Do you see people in hospital being started on TPN after 3 days of being NPO? Should they be?

A

P&P: when PN is the only nutritonal therapy for critically il pt, a pt who was healthy and well nourished before the illness can wait 7 days before initiation

pts should be started on it earlier rather than too late

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19
Q

what is the nutritional composition of TPN

A 
Carbs (10 – 70% Dextrose)
Amino acids (protein/nitrogen)
Fats (fatty acids)
Electrolytes
Vitamins
Trace elements (zinc, copper, manganese chromium etc.)
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20
Q

if giving TPN with lipids in it what must you consider when setting it up

A

use a larger filter. it prevents particulate matter or lg dropets from reaching a pt which could result in PE

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21
Q

Why don’t the fats/oils in TPN cause fat emboli? Is this a danger

A

No, it’s not a danger because the solution includes digestive enzymes – the same as if they were swallowed!

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22
Q

how is TPN usually given

A

centrally if soln is >10% dextrose but it can be given peripherally if it is 10% or less

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23
Q

potential complications of TPN from central line insertion and infusion

A 
pneumothorax from insertion
air embolism
localized infect
catheter related sepsis or bacteremia
hyperglycemia
hypoglycemia
nutrition/lyte etc imbalance from improper TPB
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24
Q

actions for pneumothorax on insertion

A
  • per HCP order remove the catheter
  • oxygen
  • chest tube
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25
Q

air embolism actions for

A
  • clamp catheter
  • L trendelenburg
  • call HCP
  • oxygen
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26
Q

if tunnel of pts CVC is infected what to do

A

remove after calling HCP

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27
Q

what to do if exit site of CVC is infected

A

call HCP and put warmcompress, daily site care, oral antibiotics

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28
Q

what do if pt hyperglycemic

A

call HCP

dr may order to slow infusion rate

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29
Q

actions if pt show signs of hypoglycemia

A

call
if PN d/c abruptly may need to restart D10W at previous rate
if pt has oral intake give 0.5 cup fruit juice and perform blood glucose monitoring; retest in 15-30min

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30
Q

is fat emulsion a major caloric source in periph or central

A

periph

central uses dextrose more

31
Q

how many calories does periph vs central PN gen have

A

periph gen 1800 calories or less

central-2000 calories or mroe

32
Q

considerations for giving PN to kids

A

ther vessels are v small-periph is a risk!

kids have less fluid in cells to begin with and are at risk of dehydration

33
Q

your pt is at risk of refeeding syndrome what might dr order

A

lytes 2-3x daily

34
Q

what is the advantage to having lipid emulsions in the PN soln directly
what is it called when the lipid emulsion is added to PN

A

dec risk of hypertriglyceridemia from rapid infusion

called 3 in 1 or 3:1 total nutrition admixture

35
Q

what is pt at risk of if they dont have lipids in their PN within 3 wks and no PO intake

A

EFAD essential fatty acid deficiency

36
Q

should you give TPN directly from fridge

A

no. let come to room temp for an hour

37
Q

what to assess TPN for and what to check before skill

A

o label of PPN bag and lipid emulsion bottle w Mar; check additive and expiry, pt name
o examine lipid soln for separation of emulsion into layers,froth etc
check compatability of meds

38
Q

how to do skill of giving TPN through central line

A

o Check soln and right label then compare label of bag to MAR, expirty date, pt name
o Check 2:1 for particulate matter and 3:1 for separation of soln
o Id pt
o Gloves and put filter on tubing. Prime. Connect to port and label and open clamp to keep line open
o Put tubing in pump open clamp completely and re flow (often 40-60)
o only inc rate gradually as PN is hyperosmolar.
o If must be d/c suddenl hang infusion of 5\% dextrose in water at same infusion rate to prevent hypoglycaemia. PN should be infused in 24hrs
o Use line solely for PN, no sample or CVP
o Don’t interrupt PN infusion and don’t exceed ordered rate
o Change IV admin sets for CPN q24hrs and when suspected contamination

39
Q

should you inc rate of infusion slowly

A

yes

40
Q

can you ever catch up TP\N

A

never

41
Q

can you use a PN line for blood samples, IV meds, CVP?

A

no

42
Q

your pt wants to take a shower can you interrupt the PN

A

no. dont interrupt for transport, blood transfusion either

43
Q

what is periph given PN better for:

correcting nutritional deficit or preventing malnutriton

A

prevneting malnutriitun

44
Q

how long is periph given PN gen used for

A

short term, less than 2 wks

45
Q

skill of PN through periph line

A

o hygiene
o label of PPN bag and lipid emulsion bottle w Mar; check additive and expiry, pt name
o examine lipid soln for separation of emulsion into layers,froth etc
o ID pt and take vitals
o Gloves. Prep IV tubing for PPN soln; run soln through tubin to remove air. Turn clamp to off and cap tubing. Same procedure for separate lipid set.
o Connect PPN soln to pts fx periph IV. Dc old PPN tubing from IV site and insert adapter of new PPN infusion tubing. Open roller clam on new tubing. Allow soln to run to ensure that tubing is patent then reg IV drip rate
o Clean periph line tubing port and insert valve at end of fat emulsion tubing into injection port of main IV cloest to pt but below infusion filter on main parenteral nutrition line and label tubing
o Open clamp on fat line and chack flow rate. Infuse lipids initially at 1ml/min for adults and 0.1ml/min for kid for first 15-30min, inc rate as ordered
o Begin PPN at ordered rate. 20% fats are infused over at least 8hrs. All lipids can hang for 12hrs as separate infusion (review ppt says lipids in periph line can hang 24hrs)

46
Q

when initially starting pt on PN how often do you take VS

what else do you assess

A

q10min for 30min

o Monitor flow rate hourly or more
o Labs daily and BG as ordered. Meas serum lipids 4hrs after dc infusion
o Monitor T q4h and regularly inspect site
o Wt, i/o, edema, breath sounds

47
Q

what would s/s of intolerance to fat emulsion be and what would you do

A

o If intolerance to fat emulsion (as shown by inc triglycerides, inc T, chills, flushing, headache N, V, diaphoresis, muscle ache, chest and back pin, dyspnea, pressure over eyes and vertigo

o Turn PPN off, notify, prep to treat anaphylactic rxn according to dr orders, record lipid allergy

48
Q

why is it easy for dehydration to occur when on PN

A

there is higher than normal glucose and hte kidney try to elim it with water following

49
Q

now stuff from VIHA order sheets not sure if important?

what to hang at what rate if TPN not avail

A

D10W at 50ml/h

50
Q

its 10:30am and the pts TPN orders arent changing, do you need to do anything

A

yes, send white and canary copies of TPN adult order form to pharmacy, keeping pink copy in chart. This is done for “same” or d/cd orders (they must be sent to pharmacy by 11

51
Q

what is deadline that new or changed TPN orders must be received by

A

12

52
Q

what is the lab draw schedule when starting TPN initially

A 
daily x2 (meas tons of stuff)
mon and thurs (diff stuff each day)

if pt has sensitive K levels that might be ordered daily

53
Q

how often should pt be weighed

A

mon and thurs

54
Q

what should be discontinued unless otherwise ordered when starting TPn

A

the pts continuous IV

55
Q

our teacher said to know the s/s of imbal lytes

s/s of hypomagnesemia and hypermagnesemia

A

very rare, esp hypermagnesemia. the following are for both although it could be divided up more i guess

    Muscular weakness
    Tremors
    Seizure
    Paresthesias
    Tetany
    Positive Chvostek sign and Trousseau sign
    Vertical and horizontal nystagmus
hypokalemia
hypocalcemia
heart rhythm irregularities
BP changes
56
Q

s/s of hypernatremia

A

-those of dehydration eg oliguria, dry skin, tachy
-alt LOC d/t neuronal cell shrinkage: confusion, Lethargy, obtundation, abnormal speech, irritability, seizures, nystagmus, myoclonic jerks
-wt loss
general weakness

57
Q

s/s of hyponatremia

A 
Nausea and vomiting
    Headache
    Confusion
    Loss of energy and fatigue
    Restlessness and irritability
    Muscle weakness, spasms or cramps
    Seizures
    Coma
58
Q

s/s of hyperkalemia

A 
fatigue or weakness
    a feeling of numbness or tingling
    nausea or vomiting
    problems breathing
    chest pain
    palpitations or skipped heartbeats
59
Q

s/s of hypokalemia

A

often no symptoms
Weakness, tiredness, or cramping in arm or leg muscles
Tingling or numbness
Nausea or vomiting
Abdominal cramping, bloating
Constipation
Palpitations
Passing large amounts of urine or feeling thirsty most of the time
Fainting due to low blood pressure
Abnormal psychological behavior: depression, psychosis, delirium, confusion, or hallucinations.

60
Q

can you check and hang a bag independently

A

no you need another nurse to check the bag

61
Q

what is metabolic bone disease and how might long-term TPN cause it

A

it is either osteoporosis or osteomalacia (abn bone growth thats faulty…somehow ha)
it used to happen from the kind of amino acids they would put in the soln-> aluminum buildup.
Basically, if its formulated slightly wrong the calcium leaches out of the bones or another part of bone health is affected and you get metb bone disease!
much less common now :)

62
Q

if you can only use peripheral IV for TPN what must be in the drs order

A

it must specify that it is peripheral so that the pharmacists prep it with more fluid etc

63
Q

somehow the TPN for your pt wont be available for 4hrs. what do you do?

A

Hang D10w at 50ml/h and call the dr

64
Q

meas of what indicates if GI function is returning and fluid status
2

A

intake and output

wt

65
Q

wt gain greater than____ indicates fluid retention

A

> 1lb a day

66
Q

which would be more likely to have soln separate 2:1 or 3:1

which would be ore likely to have particulate matter form

A

3: 1 has the lipid emulsion whcih might separate and
2: 1 more likely to have particulate

67
Q

pt has hypermetabolic condition are they good candidate for peripheral TPN

A

no

68
Q

why are lipids the primary source of calories in eripheral TPN and how is the protein content often different in peripheral vs central

A

lipids dont affect osmolarity as much, therefore easier on small periph veins
proteins alter osmolarity as dextrose does so they might include less protein in periph soln

69
Q

who would be more at risk of hypertriglyceridemia pt on central or periph TPN

A

probably peripheral??

70
Q

how should lipids hung by piggyback on periph IV flow rate be

A

p and p suggests starting a very slow infusion to let you watch for allergic rxn for first 15-30 mins. inc rate as ordered

71
Q

if you have 20% fats infusiing by piggybacked periph IV how many hours must it run over minimum. max hrs for lipids to hang

A

min 8hrs

max 12hrs

72
Q

how long afterd/c infusion should you measure lipids and why

A

minimum 4hrs or else the infusion will affect results

73
Q

how to do nutrition assessment (from Jarvis pg 198…)

A

-wt and wt history
-routine labs
-diet (maybe from food diary or get them to recall)
-eating pattern
-change in appetite
-recent sx, trauma, burns, infect
-chronic illness
-NVD or constipation
-food allergies or intolerances
-meds or nutritional supplements or both
-self care behaviours
alcohol or illegal drug use
-exercise

objective

  • BMI
  • skin hair, lips eyes tongue gums nails msksltl neuro
74
Q

what is more sensitive measure of nutrtional status albumin or prealbumin

A

prealbumin has shorter half life of 48hrs and thus is more sensitive

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